The present study aimed to assess the diagnostic capabilities of DSs at the end of the “Oral Pathology and Medicine” academic course compared to junior and senior GDPs in correct visual recognition of lesions suspected of malignancy.

Dental students and GDPs awareness and knowledge about oral cancer has been well documented in the literature, though it is challenging to find studies that directly compare the diagnostic skills of students and professionals [14, 15].

In the present study, for the first time, both groups were subjected to the same questionnaire to evaluate the role of academic education on the diagnostic abilities of students compared to the clinical experience of dentists with different levels of experience. Diagnostic accuracy was assessed through an anonymous questionnaire consisting of clinical photographs of various oral lesions using a 2-score model. Specifically, this approach was chosen to better reflect real-world clinical decision-making. In clinical practice, sometimes it is necessary to translate their level of suspicion into a binary management decision (i.e. performing an incisional biopsy to confirm suspicion of malignancy vs. clinical follow-up), even when their diagnostic confidence varies. Therefore, responses indicating any degree of suspicion for malignancy were considered clinically actionable and classified as positive, whereas responses indicating a tendency toward benignity were classified as negative. At the same time, to further explore the impact of diagnostic uncertainty, we calculated the restricted diagnostic accuracy excluding all uncertain responses and assessed the level of uncertainty in each group.

Our findings reveal that DSs demonstrated a higher diagnostic performance than JDPs and SDPs, particularly in the early stages of OSCC revelation (sensitivity: DS group 79%; JDP 55.3%; SDP 56.7%). Furthermore, DSs exhibited lower levels of uncertainty in their responses. Few studies have directly investigated the impact of academic coursework in oral medicine and pathology on students’ diagnostic skills. Hassona et al. assessed students’ diagnostic capabilities using clinical images and found that those in later years of study exhibited higher diagnostic accuracy [14]. Kujan et al. demonstrated that the limited exposure to Oral Medicine wards during dental education as a significant barrier to developing diagnostic competency [16]. In our study, students completed the questionnaire immediately after concluding their coursework in Oral Pathology and Medicine, which includes both lectures and clinical internships in the Oral Medicine ward. This course, undertaken in the third year of the dental curriculum at the University of Bologna, represents one of the students’ first clinical training experiences. Given that the first two years primarily focus on basic sciences, these results suggest that a recent intensive training and education in oral medicine, rather than clinical experience, can enhance diagnostic proficiency even among students with limited clinical experience. Indeed, dental practitioners were not evaluated following any recent training which likely enhanced short-term recall and performance.

The study also highlights concerning gaps in the diagnostic abilities of GDPs, regardless of their years of experience. Both JDPs and SDPs exhibited lower diagnostic accuracy and higher levels of uncertainty compared to students. The absence of significant differences between JDPs and SDPs further supports the notion that clinical experience alone does not compensate for the lack of continuous, structured cancer education. Prior research has reported similar findings: knowledge acquired during dental school declines over time if not actively reinforced, and GDPs often experience diagnostic uncertainty when confronted with oral lesions, frequently opting to refer patients to specialists [17,18,19]. While this may initially appear positive as GDPs acknowledge their limitations in Oral Medicine and Pathology and seek specialist input, it leads to a burden on specialists, including managing cases that could potentially be handled more straightforwardly, thereby contributing to lengthy waiting lists for specialist consultations [20].

One potential strategy to improve GDPs’ diagnostic performance is the implementation of continuous education programs focused on oral cancer recognition. Additionally, the development of easy-to-use, non-invasive diagnostic aids for OSCC could provide primary care providers with reliable tools to facilitate early detection. Current adjunctive techniques, such as the use of visualization tools like the VELscope, have not demonstrated a substantial impact on improving diagnostic accuracy among general dentists [21]. Future research should aim to develop validated diagnostic tools that differentiate OSCC from benign and reactive oral lesions, thereby enhancing GDPs’ ability to identify high-risk cases while reducing unnecessary specialist referrals.

Although the present study provides valuable insights, certain limitations must be acknowledged. For example, the assessment of diagnostic accuracy was based on an anonymous questionnaire utilizing digital images of oral lesions rather than direct patient examination.

In recent years, advances in digital technology—particularly the evaluation of clinical images through the use of instant messaging services and high-resolution smartphone cameras—have facilitated the exchange and clinical application of images among practitioners for diagnostic purposes, treatment planning, and patient management, thereby enabling faster and more accurate clinical decision-making [22, 23]. Moreover, in an educational context, digital images have also proven invaluable in teaching the clinical characteristics of various oral pathologies during both undergraduate and postgraduate training.

While visual inspection is the primary step in oral cancer screening and photographic assessment has been validated as a reliable educational tool in oral medicine, it does not fully replicate the complexity of in-person diagnosis, which involves palpation, lesion texture evaluation, and patient history consideration which are not captured in static images. Nonetheless, previous studies have demonstrated that regular exposure to clinical images significantly improves diagnostic proficiency, supporting the validity of our methodology [22, 24, 25]. However, direct interaction with patients who present with oral lesions remains the most effective way to develop diagnostic skills in both students and healthcare professionals [14]. Therefore, the present study should be interpreted as an evaluation of participants’ ability to visually recognize lesions suspected of malignancy rather than a comprehensive assessment of clinical diagnostic competence.

Finally, DSs were assessed immediately after completing the oral pathology and medicine course, this represents a deliberate methodological choice aimed at evaluating the immediate educational impact of structured, cancer-focused academic training rather than long-term skill retention. Higher performances of students in the visual OSCC recognition respect to GDPs suggest that without active reinforcement, the diagnostic proficiency acquired during dental school diminishes over time. However, this finding should be interpreted with caution, as another potential limitation of the present study is the heterogeneity in recent exposure to oral medicine education or clinical experience, particularly among participants in the JDPs and SDPs groups. Indeed, dental practitioners may have different academic backgrounds (e.g., different universities of training and degrees) and a different clinical case mix depending on their individual private practice. Furthermore, the analysis did not account for potential confounding variables such as frequency of exposure to oral lesions, or participation in continuing education activities in oral medicine, as these data were not collected. Future studies should include these factors to better clarify their potential influence on diagnostic performance.